From the Guidelines
The recommended workup for panic attacks should begin with a comprehensive clinical evaluation to rule out medical conditions that can mimic panic symptoms, followed by a detailed psychiatric assessment to identify comorbid conditions, and treatment with cognitive behavioral therapy (CBT) as first-line, particularly panic-focused CBT. This approach is supported by recent guidelines, including those from the Journal of the American Academy of Child and Adolescent Psychiatry 1, which suggest that combination treatment (CBT and an SSRI) could be offered preferentially over monotreatment to patients with anxiety disorders, including panic disorder.
Initial Evaluation
The initial evaluation should include:
- A thorough medical history
- Physical examination
- Basic laboratory tests such as complete blood count, thyroid function tests, electrolytes, and an ECG to exclude cardiac causes
- Screening for substance use, particularly stimulants, caffeine, and alcohol, which can trigger or worsen panic symptoms
Psychiatric Assessment
A detailed psychiatric assessment is essential to identify comorbid conditions like depression, other anxiety disorders, or trauma-related disorders. This assessment should be conducted by a qualified mental health professional and may involve the use of standardized symptom rating scales to optimize treatment response and remission, as suggested by the Journal of the American Academy of Child and Adolescent Psychiatry 1.
Treatment
For treatment, cognitive behavioral therapy (CBT) is considered first-line, particularly panic-focused CBT that includes education about panic, cognitive restructuring, and exposure techniques. Medication options include SSRIs (such as sertraline 50-200mg daily or escitalopram 10-20mg daily) or SNRIs (venlafaxine XR 75-225mg daily), which typically require 4-6 weeks for full effect and should be continued for at least 6-12 months after symptom resolution, as recommended by the Annals of Internal Medicine 1. For acute management, benzodiazepines like lorazepam 0.5-2mg as needed can provide rapid relief but should be used cautiously due to dependence risk.
Lifestyle Modifications
Lifestyle modifications are also important, including:
- Regular exercise
- Adequate sleep
- Stress management techniques
- Avoiding caffeine, alcohol, and nicotine This comprehensive approach addresses both the immediate symptoms and underlying factors contributing to panic attacks, and is supported by recent guidelines and studies, including those from the Journal of the American Academy of Child and Adolescent Psychiatry 1 and the Annals of Internal Medicine 1.
From the FDA Drug Label
Dose Titration Treatment may be initiated with a dose of 0. 5 mg three times daily. Depending on the response, the dose may be increased at intervals of 3 to 4 days in increments of no more than 1 mg per day. The FDA drug label does not answer the question.
From the Research
Diagnostic Work-up for Panic Attacks
The diagnostic work-up for panic attacks is crucial to rule out other diseases that may present with similar symptoms, such as acute coronary syndrome or neurological emergencies 2.
Recommended Tests and Evaluations
- A thorough medical history and physical examination are essential to identify any underlying medical conditions that may be contributing to the panic attacks.
- Laboratory tests, such as a basic metabolic panel, may be ordered to rule out any electrolyte imbalances or other metabolic disorders that could be triggering the panic attacks 3.
- Thyroid function tests, including T3, T4, and T7 levels, may also be ordered to rule out any thyroid dysfunction, as there is evidence of a blunted TSH response to TRH stimulation in patients with panic disorder 4.
- A psychiatric evaluation is also necessary to diagnose any underlying anxiety disorders, such as panic disorder, and to develop an effective treatment plan.
Treatment Options
- Selective serotonin reuptake inhibitors (SSRIs) and benzodiazepines are standard first-line pharmacologic treatments for panic disorder 5, 6.
- Cognitive-behavioral therapy (CBT) is also a highly effective treatment for panic disorder, and may be used in conjunction with medication 6.
- Other treatment options, such as serotonin-norepinephrine reuptake inhibitors, tricyclic antidepressants, and monoamine oxidase inhibitors, may also be considered, although the evidence for their effectiveness is limited 5, 6.